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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> APPLICATION <br /> rl (For Non-Transferable, Revocable, and Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT <br /> LIQUID WASTE <br /> Application i"e by mad 10 c on lansiness in the jurisdictional area of the S�doaquigcal H Ith istrict <br /> ,;Business Name (DBA) r� <br /> z OwnerAddress_ 1` <br /> Address <br /> J Firm Partners, Addresses an¢Telepls ne Numbers <br /> aBusiness Telephone No. 7 � - Emergency Telephone No. j <br /> J1 Contractor Licence No. <br /> L Applicants Name (Print) �— r" ► Title " +< �' Y Date <br /> Please check Applicable Category (1-7)and Fill in the Required Information <br /> 1. ❑ PUMPER VEHICLE PERMIT REGISTRATION (FOR EACH VEHICLE) t- <br /> For July 1, June 30, 19 <br /> Disposal Sites <br /> Description(Make/Yr., Color) <br /> Serial No. CAL. License No. <br /> CAL. License Renewal No. <br /> Capacity Gal., Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored 4. <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST <br /> R.S. or R.C.E. Name R.S. or R.C.E. No. <br /> Test Lo tion Test Date/Time <br /> 4. SANITATION PERMIT tr 11 <br /> Job Address/Location1 <br /> f <br /> 6O ner _ 1l "F '�t�(� J���� '� i Address 6V <br /> SEPTIC TANK ❑ CESSPOOL UC ACHING FIELD 1:1SEEPAGE PIT 11PACKAGE PLANT <br /> ElPERMANENT 11TEMPORARY 0 NEW ❑ REPAIR ❑ OTHER <br /> 5. ❑ CHEMICAL TOILETS For July 1, -June 30, 19 <br /> Type Construction Disposal Site <br /> No. of Units Equipment Storage/Cleaning Location(s) <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1, -June 30, 19 <br /> Operator Name <br /> Where Certified <br /> Plant Location <br /> Plant Capacity No. Units Served <br /> 7. ❑ LAUNDRY For July 1, -June 30, 19 <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., ❑ More Than 1,000 Sq. Ft. <br /> DRY CLEANING, Chemicals Used/Amount/Mo. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules an ula of th San Joaquin Local Health District. 1 <br /> 1 <br /> APPLICANT'S SIGNATURE X <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> BASE EXPLANATION BILLING REMITTANCE $ REMIT <br /> DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS — <br /> PENALTY C.• <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No '. Permit.r_,t Nat issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA5201 <br /> C ki <br />